Description: Universal Protocol: The Final Safety Stop
Clinical Issue: In 2017, The Joint Commission received 104 reports nationally of wrong patient, wrong site, wrong procedure events. In Pennsylvania alone, there were 60 reported events between October 2016 and September 2017. There is an upward trend in wrong site surgery events reported in Pennsylvania. Description of the Team: Nursing Leadership, Anesthesia Providers, Physicians, and Technologists Preparation and Planning: Multidisciplinary team including Nursing Education, Surgeons, Clinical Directors, and Anesthesia discussed pre implementation audits. Focus points of the education were to include Understanding current safety trends within the Perioperative Services Division Verbalize the essential elements of the procedural timeout per the entity wide Universal Protocol Policy Utilize the Agency for Healthcare Research & Quality's TeamSTEPPS framework to facilitate effective communication Articulate the escalation plan for non-compliance
Assessment: Pre-implementation audits revealed a 60% compliance rate for timeout compliance. A process and strong culture of safety was needed to empower team members to stop the time out in an inaccuracy was identified. A firm escalation plan for non compliance was not in place. Implementation: Pre/Post audit toolEducation sessions for the entire division Post educational session quiz Visual aids Mini education sessions for inpatient units for bedside procedures Outcome: Post implementation audits have shown overall sustained compliance rate at 81% from July 2019 to September 2019.Implications for Perioperative Nursing: An interdisciplinary team approach to timeout education can increase overall compliance rate.